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Blanchard, Harold TOWN OF Q U'EENSB UR Y Pine View Cemetery and Crematorium) 17 Quaker Road, Queenshury, NY. 12804.5902 (518) 74 5.44 76 h"PI'Mm.queensbury.net (518) 745.4477 Funeral Director: BA !F7 Name of Deceased: ��nc�4rt- Case Number: Z Z2 Date of Cremation: ? 15 z o0 Retort: U w ST- Time Cremation Started: 7; , Time Cremation Completed: 10 t�S Type of Container: Remarks: q• 3 U ' M q, 10 ;9M w :IL HO 'lle o/ Nntttral Beauty ... A Good Place to Lice • 27Z Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12864 Cemetery Office: (518)745-4476,Crematorium: (518)745-4477 Authorization to Cremate The undersigned requests and aWtortms Pine View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of __11 ttnr��� C, (�fCl Hakz � (Name) (Sex) 2y5� I�hi�e KI(c-b s ��. EtAv-_r 0 �y IZ ZS� (Street) (City (isi Code ) (ZrP ) who died on T" day of ho, at C`1 O os C�II S 1��.' I(x� l iC --ATQb�� _r? (Place) t(Address) Name and address of nearest living relative or name of person 8u1h0ftk 8 MOUMort: char 1(� re �1ar�c r� l (Name) (A �- Relationship to the demss�ed Name of Funeral Home IMPORTANT: I represent that to the best of my iahowledge,the ( ( fbatt� pack,power cell,radloactive implant or radioactive device in h or her (Cirr9e Oneti I certify that I have full power and andhorization to arrange for the crernadon of the rernains and to direct the disposition of the cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and save hannim Pine View Crematorium from arty and ad cluns and demands for foss or damages vddch may be made against them by reason of or connected with the aeon of said remains as darted.ubedw such daims or demands are or are not wholly groundless,false or fraudulent. 7 - rib J (Signature and Address of Relative or Legal Representative) Signed on this date: t 1—)© Disposition of Cremated Remains I hereby direct pine View Crematorium to dispose of the cremated remains as follows. Mail to Other arrangements-Please spew. if pulverization of cremated remains is requested,check here Revision:April 18,2007